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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-C86UFB

FACILITY NAME
Nazirah House
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
3201248
FACILITY ADDRESS
4560 Imperial St
FACILITY PHONE
(604) 438-6579
CITY
Burnaby
POSTAL CODE
V5J 1B6
MANAGER
Sujit Mandal

INSPECTION DATE
October 15, 2021
ADDITIONAL INSP. DATE (multi-day)
October 19, 2021
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3.5
ARRIVAL
12:15 PM
DEPARTURE
01:15 PM
ARRIVAL
01:00 PM
DEPARTURE
03:30 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records and information provided by the facility staff at the time of inspection.
The following areas were reviewed:
Licensing
Physical Facility
Staffing
Polices & Procedures
Care & Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records and Reporting

As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation.
Visit the CCFL website at www.fraserhealth.ca/residentialcare for:

· Additional resources and
· Links to the Legislation (CCALA & RCR)

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31780 - RCR s.35(2)(a) - A licensee must ensure that laundry facilities (a) if used by persons in care, have a slip resistant floor surface.
Observation: The laundry area does not have a slip resistant flooring surface and 1 PIC has access to laundry facilities and is assists with the laundry.

Corrective Action(s): Please ensure that the laundry area has a slip resistant flooring surface.

Date to be Corrected: November 15, 2021

STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Staff records provided showed 1 staff had last performance review was completed on September 13, 2018.

Corrective Action(s): Please ensure that the performance of each staff is reviewed as per the facility policy.

Date to be Corrected: November 15, 2021

CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: 1/4 PIC's care plan did not include the latest meal time assist instructions from the last assessment for the PIC . Staff assisting with this inspection informed LO that the instructions were posted on the kitchen cabinet but has been removed by someone.

Corrective Action(s): Please ensure that each care plan is reviewed annually and modified with any substantial change in the circumstances of the PIC.
Date to be Corrected: November 15, 2021

NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: The daily lunch menu for the week days had no clear indication of what items are being served during each lunch and there was no menu list for the weekends There was no indication these meals contained at least 3 food groups.

Corrective Action(s): Please ensure that each menu for each day clearly identifies morning, noon and evening meal with each meal containing at least 3 food groups as described in Canada's Food Guide.

Date to be Corrected:
November 15, 2021

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: The facility menu did not list any snack provided to PICs however, there was fruits and yogurt available in the kitchen. The staff presented stated that snacks were provided to PICs. Hence, it could not be determined during the inspection if snacks served to PICs were from 2 food groups.

Corrective Action(s): Please ensure that each weeks' menu has at least 2 nutritious snacks listed appropriately, with each snack containing at least 2 food groups.

Date to be Corrected: November 15, 2021


Comments

Thank you to the staff and Director Residential services of Nazirah House for their assistance during the inspection today. This report was written after the staffing records were received and reviewed by the Licensing Officer.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Nov 15, 2021

Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.